PROJECT SUMMARY Liver cirrhosis affects greater than 5 million individuals in the United States. Recent national data show a 59% increase in cirrhosis prevalence and a 52% increase in cirrhosis mortality from 2001-2013. Despite effective hepatitis C (HCV) eradication with new direct-acting antivirals, the burden of chronic liver disease and hepatocellular carcinoma will continue to rise, resulting in up to $10.6 billion in annual health care costs. Cirrhosis management is highly complex and requires specialized training, however, due to workforce shortages, 82% of cirrhosis-related hospitalizations occur at non-transplant hospitals and only 45% of cirrhotic patients see a gastroenterologist or hepatologist within one year of hospitalization. Overcoming barriers to access to specialty care may be feasible with telehealth, which has shown promise in HCV treatment, HIV, and other chronic diseases, however, this approach has not been rigorously investigated in cirrhosis. The proposed research fills gaps in cirrhosis care management through the following innovations: 1) identifying modifiable barriers to high quality cirrhosis care using the largest, multi-center database to date; 2) tailoring a telehealth program specific to cirrhosis using implementation science principles for rapid adoption into clinical practice; and 3) delivering a telehealth intervention to geographically distant and diverse sites. The hypothesis that telehealth may improve the access and quality of care in cirrhosis will be pursued through the following interrelated Specific Aims: (1) investigate how access to specialty care impacts process of care and clinical outcomes among a national VA cohort, (2) conduct qualitative interviews to explore barriers and facilitators of access to care and potential uses for telehealth among clinicians at low and high specialty-care- access sites, and (3) pilot-test a telehealth intervention to provide timely hepatology care to patients with cirrhosis complications at two community hospitals, and enhance non-expert provider training through problem- based learning. The project aims will identify modifiable factors to improve the delivery of high-quality care for cirrhosis and establish the feasibility of a telehealth strategy to increase access to specialty care. The PI is Assistant Professor of Medicine, a hepatologist, and hypothesis-driven clinical researcher at the University of Pennsylvania. Her experience in patient-oriented and observational research and a Master's in Health Services and Outcomes Research have prepared her to execute the project aims. The proposed research will be combined with carefully structured mentorship by faculty with complementary expertise, institutional support, and coursework in advanced observational methods, clinical trials, information technology, and implementation science. This award and protected time will allow the applicant to build an independent NIH-funded research career and become a leader in technology-based approaches to improve care delivery in chronic liver disease, an area that is lacking to date, and with potential applications to other chronic diseases.